20
Original Article
Rev. Latino-Am. Enfermagem 2015 Jan.-Feb.;23(1):20-7 DOI: 10.1590/0104-1169.0144.2520
www.eerp.usp.br/rlae
Comparative analysis of non-adherence to medication treatment for systemic arterial hypertension in urban and rural populations1 Patricia Magnabosco2 Eliana Cavalari Teraoka3 Edward Meirelles de Oliveira4 Elisangela Aparecida Felipe5 Dayana Freitas6 Leila Maria Marchi-Alves7 Objective: to evaluate the indexes and the main factors associated with non-adherence to medication treatment for systemic arterial hypertension between urban and rural areas. Method: analytical study based on an epidemiological survey with a sample of 247 hypertensive residents of rural and urban areas, with application of a socio-demographic and economic questionnaire, and treatment adherence assessment. The Pearson’s Chi-square test was used and the odds ratio (OD) was calculated to analyze the factors related to non-adherence. Results: the prevalence of non-adherence was 61.9% and it was higher in urban areas (63.4%). Factors significantly associated with non-adherence were: male gender (OR=1.95; 95% CI 1.08-3.50), age 20-59 years old (OR=2.51; 95% CI 1.44-4.39), low economic status (OR=1.95; 95% CI 1.09-3.47), alcohol consumption (OR=5.92, 95% CI 1.73-20.21), short time of hypertension diagnosis (OR=3.07; 95% CI 1.35-6.96) and not attending the health service for routine consultations (OR=2.45; 1.35-4.42). Conclusion: the socio-demographic/economic characteristics, lifestyle habits and how to relate to health services were the factors that presented association with nonadherence regardless of the place of residence. Descriptors: Hypertension; Medication Adherence; Urban Population; Rural Population.
Paper extracted from doctoral dissertation “Systemic arterial hypertension in urban and rural population of Sacramento/MG: prevalence
1
and non-adherence to medication treatment”, presented to Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil. Doctoral student, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research
2
Development, Ribeirão Preto, SP, Brazil. Assistante Professor, Universidade Federal de Uberlândia, Uberlândia, MG, Brazil. Doctoral student, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research
3
Development, Ribeirão Preto, SP, Brazil. Scholarship holder from Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil. Doctoral student, Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil. Scholarship
4
holder from Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil. Social worker, Escola Eurípedes Barsanulfo, Sacramento, MG, Brazil.
5
Doctoral student, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Centro Colaborador da OMS para o Desenvolvimento
6
da Pesquisa em Enfermagem, Ribeirão Preto, SP, Brazil. RN, UBS/PSF Gilberto Arthur Abate, Prefeitura Municipal de Frutal, Frutal, MG, Brazil. PhD, Professor, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Centro Colaborador da OMS para o Desenvolvimento da
7
Pesquisa em Enfermagem, Ribeirão Preto, SP, Brazil. Corresponding Author: Patrícia Magnabosco Universidade Federal de Uberlândia. Faculdade de Medicina Av. Pará, 1720 Bairro: Umuarama CEP: 38400-902, Uberlândia, MG, Brasil E-mail: [email protected], [email protected]
Copyright © 2015 Revista Latino-Americana de Enfermagem This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC). This license lets others distribute, remix, tweak, and build upon your work non-commercially, and although their new works must also acknowledge you and be non-commercial, they don’t have to license their derivative works on the same terms.
Magnabosco P, Teraoka EC, Oliveira EM, Felipe EA, Freitas D, Marchi-Alves LM.
Introduction
21
of the disease, ignorance, illness in the family context
Non-adherence
to
medication
therapy
is
a
worldwide problem by reducing the therapeutic results, especially chronic diseases, and increasing the costs of health systems(1). Conceptually, non-adherence should be assumed as a multi-dimensional construct. It is related not only to medication intake or not, but to how the patients “manage” their treatment: behavior in relation to dose, time, frequency and duration(2).
and self-esteem) and how people with SAH relate with the health service(1). Thus, given the diversity of contexts between residents of urban and rural areas, this study aims to evaluate the indexes and the main factors associated with non-adherence to medication treatment for SAH between urban and rural areas of a Brazilian city.
Method
Few studies in Brazil and around the world describe
The study was conducted in a city located in the
the adherence rates among hypertensive patients,
Triângulo Mineiro, region of Alto Paranaíba in the State
especially in rural areas. Most investigations have been
of Minas Gerais, which has a population of 23,880
focused on the evaluation in urban centers and these
inhabitants, with 19,278 living in the urban area and
data cannot be extended to rural areas, as populations
4,602 in the rural area. The population aged 20 years
have very different demographic characteristics, food
or older is 14,217 people, with 12,974 in the urban and
and cultural habits, occupation types and access to
1,243 in the rural area(13). The coverage of the Family Health Strategy (FHS)
health care . (3)
The literature shows that the prevalence of
in the city is 85.9% and it has six teams, one with only
non-adherence of people with Systemic Arterial
rural activities, covering approximately 700 families
Hypertension (SAH) to medication treatment is quite
distributed in six micro-areas. The long distances
varied (4). Research conducted with hypertensive
and difficult traffic conditions and mobility between
patients in outpatient clinics of Brazilian hospitals
areas are some of the main challenges for interaction
showed a percentage of non-adherence of 86.7% in
with rural communities, historically relegated to low
São José do Rio Preto (SP) (5) and 12.7% in Ribeirão
priority.
. In the primary care of a small town
For this study, we investigate a population of 1,243
in Rio Grande do Sul, the non-adherence rate was
adults registered in the rural FHS and 4,690 people
34.3% (7).
was
enrolled in two FHS teams in the urban area. The
and, in Maringá (PR), it was equal to
sample size determination was based on the population
Preto (SP)
26.8%
(8)
(6)
In
Teresina
(PI),
non-adherence
proportion estimate, using a SAH prevalence rate equal
64.0% (9). Studies in rural areas of different countries have
to 44%, maximum value according to studies conducted
also shown varying rates of non-adherence to medication
in Brazil(14). Individuals were selected through random
treatment for SAH. Rates of 66.0% in Turkey(10) and
sampling that included 5,933 adult inhabitants resident
60.1% in the United States
were found. In Brazil, a
in rural and urban areas, with correction for finite
study conducted in the state of Minas Gerais showed
populations and adjustment for a refusal population of
non-adherence rate of 28%(12).
20%, respecting the population density of each area.
(11)
The world report shows that this variability in the frequency of adherence depends on the method used for its estimation, population characteristics investigated
The confidence interval was set as 95% and the design error as 2.5%. For each area covered by the FHS teams, a sample corresponding to 563 participants from urban and 153
and the sample size . (1)
Regarding the factors that influence treatment
from rural areas was estimated. For the data collection
adherence, researchers point out multiple causes, i.e.
procedure, a sample draw was performed in four stages.
adherence depends on the disease (chronicity, absence
The sampling units of the first stage were carried out
of
according to the FHP coverage areas of urban and rural
symptoms
and
late
consequences),
treatment
(medication consumed), characteristics and beliefs
regions of the municipality.
of people (gender, age, ethnicity, marital status,
In the urban area, the second stage comprised
education and socio-economic status), life habits,
sampling by street, the third by residences, and
cultural aspects (lack of perception of the seriousness
the fourth by choosing a resident. To maintain and
www.eerp.usp.br/rlae
22
Rev. Latino-Am. Enfermagem 2015 Jan.-Feb.;23(1):20-7.
ensure the random characteristic of the sample, it
this study(16); difficulty to access the health services;
was determined that the selection of individuals would
type of health service used (health insurance/private
include the individual with the first upcoming birthday,
or SUS); reason why the health service was searched
from the date of the interview, among the inhabitants of
(only in emergency cases, for routine consultations -
the residence drawn.
at least one medical visit every six months(14) - or to
The selection of participants in the rural area occurred by random drawing from the numeric register
get medications) and amount of anti-hypertensive pills prescribed a day.
of families in the FHS, registered in the Primary Care
For the assessment of non-adherence to treatment
Information System (SIAB) of the Municipal Health
of SAH, the instrument “Questionnaire of Adherence to
Secretariat. For the selection of the individuals, the
Medications - Qualiaids” (QAM-Q) was used, developed
criterion valid for the urban population was used.
and
validated
in
Brazil(2).
The
questionnaire
was
Preliminarily, the individuals were informed about
developed to address the act (if the individual takes and
the objectives and procedures of the study and, next,
how much medication is taken), the process (such as
they were invited to participate in the study. The data
how medication is taken in seven days, if he/she skips, if
collection was carried out after signing the Informed
he/she takes it abnormally, if he/she has “breaks”) and
Consent Form (ICF). The sample included individuals
the adherence results (in this case, if his/her pressure
aged 20 years or older who reported having SAH and
was under control).
excluding pregnant women and people with serious
To
sort
the
interviewee
as
non-adherent
a
psychiatric illness or mental disability informed by a
composite measure was constructed, in which the
relative. These criteria determined the subject studied
presence of one of these conditions was sufficient:
in 247 hypertensive patients (194 in urban areas and 53
either not taking the correct amount (80% - 120% of
in rural areas).
the prescribed doses), or not taking it the right way
Data collection was carried out between January and
(without “breaks”, “erratic intake”, abandonment or
August 2013, through a semi-structured questionnaire
“partial adherence”), or to report that his/her blood
and instruments that permitted the evaluation of socio-
pressure was altered(2).
demographic and economic variables, risk factors for
To analyze the association between the dependent
SAH, knowledge of hypertensive condition, medications
variable (non-adherence to treatment of SAH) and
in use, access to health services and reasons why
socio-demographic and economic variables, clinical/
participants seek care.
treatment/lifestyle
Non-adherence
to
medication
treatment
and
access
to
health
services,
of
Pearson’s Chi-square test was used. The odds ratio
SAH was the dependent variable addressed and the
(OD) was calculated with the respective 95%confidence
independent variables of interest were: gender; age
intervals for each variable studied. The significance
(young/adult or elderly); skin color reported according
level was set as α=0.05. The software SPSS Windows
to the perception of the individual (white or non-white);
Statistical Package for the Social Sciences (SPSS),
years of education (< 8 years or ≥ 8 years); economic
version 17.0 was used.
status (classified based on the criteria of the Economic
This study was approved by the Research Ethics
Classification of Brazil according to the Associação
Committee of the University of São Paulo at Ribeirão
Brasileira de Empresas de Pesquisa(15), which takes
Preto College of Nursing (EERP-USP) under protocol
education and consumer goods for reference, where
188/2012.
the variation occurs between Class A, which is the best stratum, up to class E, with the most unfavorable conditions);
sedentary
lifestyle
(not
Results
performing
physical activity at least three times/week for at least
The prevalence of non-adherence to medication
30 minutes/day); smoking (consumption of at least one
treatment of SAH as a combined measure of QAM-Q
cigarette/day); alcohol consumption (consumption of
was 153 (61.9%), being higher in the urban area,
more than 30 g of ethanol/day for men and 15g/day for
123 (63.4%), than in rural area, 30 (56.6%). No
women)
; time of diagnosis of SAH (up to 3 years or
association was found between place of residence and
≥ 3 years), according to criteria adopted by the authors
non-adherence to treatment (OD= 1.32; 95% CI 0.71-
of the non-adherence measurement instrument used in
2.46).
(14)
www.eerp.usp.br/rlae
23
Magnabosco P, Teraoka EC, Oliveira EM, Felipe EA, Freitas D, Marchi-Alves LM. The distribution frequencies of socio-demographic and
economic
characteristics,
clinical/treatment/
lifestyle and access to health services in urban and rural populations are shown in Tables 1 and 2.
Table 1 - Distribution of hypertensive patients according
Table 2 - (continuation) Rural (n=53) %
Urban (n=194) %
Total (n=247)
Routine visit*
62.3
64.4
63.6
To get medication
5.7
7.6
3.6
Only emergency
32.1
28.8
32.8
Study variable % Reason for seeking the health service
to socio-demographic/economic and lifestyle variables of urban and rural population. Sacramento, MG, Brazil, 2013
* Routine visit (at least one medical visit every 6 months)
Non-adherence
measured
by
the
proportion
Rural (n=53) %
Urban (n=194) %
Total Population (n=247)
Female
56.6
72.7
69.2
population and 16 (30.2%) in rural areas. As regards
Male
43.4
27.3
30.8
taking the medication measured by the QAM-Q, 82
≥ 60 years old
39.6
66.0
60.3
Up to 59 years old
60.4
34.0
39.7
White
92.5
73.2
77.3
Non-white
7.5
26.8
22.7
< 8 years of study
84.9
71.6
74.5
≥ 8 years of study
15.1
28.4
25.5
A/B
13.2
29.4
25.9
took it erroneously in urban areas and six (11.3%) in
C/D/E
86.8
70.6
74.1
rural areas; 15 (7.7%) had half adherence in urban
No
84.9
85.6
85.4
Yes
15.1
14.4
14.6
No
88.7
90.2
88.7
Yes
11.3
9.8
11.3
Study variable % Gender
Age Group (years)
Skin color
of dosages of QAM-Q was 53 (27.3%) in the urban
(42.3%) people were considered non-adherent in the urban area and 21 (39.6%) in rural areas; of these, 12 (6.2%) in the urban area and three (5.7%) in rural areas reported taking medications at changed times; 10 (5.2%) people in the urban area had “breaks” in
Education
Economic Status*
Smoking†
Alcohol consumption‡
* Economic Status A/B (more favorable) and C/D/E (less favorable) † Smoking (consuming at least one cigarette/day) ‡ Alcohol consumption (consumption of more than 30 g ethanol/day for men and 15g/day for women).
the use of antihypertensive medications, but none among hypertensive patients in rural areas; 20 (10.3%)
areas and seven (13.2%) in rural areas; six (3.1%) exchanged dose levels in the urban and one (1.9%) in the rural area; three (1.5%) partially abandoned medication treatment in the urban and none in the rural area; 21 (10.8%) totally abandoned the medication in the urban and five (9.4%), in the rural population. Regarding treatment results, 87 (44.8%) residents in the urban and 20 (37.7%) in the rural area reported
Table 2 - Distribution of hypertensive patients according
that their blood pressure was altered the last time it
to clinical variables/treatment and access to health
was measured.
services in urban and rural population. Sacramento, MG, Brazil, 2013 Study variable %
Rural (n=53) %
Urban (n=194) %
Total (n=247)
Time of diagnosis (Systemic Arterial Hypertension)
The frequency distribution and association between non-adherence and the variables studied are presented in Tables 3 and 4. The reasons reported by the hypertensive patients
More than 3 years
77.4
77.8
83.0
Up to 3 years
22.6
22.2
17.0
1 to 2
48.1
53.8
52.3
forgetfulness (16.8%), economic factors (5.9%) and
≥3
51.9
46.2
47.7
others (4.2%).
Health Insurance/Private
3.8
22.7
23.9
Brazilian Unified Health System
96.2
77.3
76.1
Pills/day
Service Type
relative to non-adherence to medication treatment were: absence of symptoms (51.3%), side effects (21.8%),
The factors that hampered the access to health services were: distance in relation to the local of care (77.6%) and lack of vacancies (15.6%) according to the
Difficulty to access No
60.4
68.8
66.4
residents of the rural area, and availability of vacancies
Yes
39.6
32.0
33.6
(46.0%) and limited mobility (44.4%) according to
(continue...)
www.eerp.usp.br/rlae
urban population.
24
Rev. Latino-Am. Enfermagem 2015 Jan.-Feb.;23(1):20-7.
Table 3 - Univariate analysis of the association between non-adherence and socio-demographic/economic and lifestyle characteristics. Sacramento, MG, Brazil, 2013 Study variable
Non-adherence(%)
Likelihood Ratio
Rural (n=53)
Urban (n=194)
Total (n=247)
Female
50.0
58.9
57.3
1
Male
65.2
75.5
72.4
1.95
≥ 60 years old
47.6
54.7
53.7
1
Up to 59 years old
62.5
80.3
74.5
2.51
White
59.2
60.6
60.2
1
Non-white
25.0
71.2
67.9
1.39
< 8 years of study
55.6
62.6
60.9
1
≥ 8 years of study
62.5
65.5
65.1
1.19
A/B
42.9
50.9
50.0
1
C/D/E
58.7
68.6
66.1
1.95
No
55.9
60.8
59.7
1
Yes
62.5
78.6
75.0
2.02
No
53.2
60.6
58.4
1
Yes
83.3
89.5
89.3
5.92
Gender
Age Group (years)
Skin color
Education
Economic status †
Smoking‡
Alcohol consumption§
* † ‡ §
Confidence Interval (95%)
p*
(1.08-3.50)
0.025‡
(1.44- 4.39)
0.001‡
(0.74-2.62)
0.301
(0.66-2.17)
0.553
(1.09-3.47)
0.023‡
(0.90-4.51)
0.081
(1.73-20.21)
0.002‡
Pearson’s chi-square test (p
Original Article
Rev. Latino-Am. Enfermagem 2015 Jan.-Feb.;23(1):20-7 DOI: 10.1590/0104-1169.0144.2520
www.eerp.usp.br/rlae
Comparative analysis of non-adherence to medication treatment for systemic arterial hypertension in urban and rural populations1 Patricia Magnabosco2 Eliana Cavalari Teraoka3 Edward Meirelles de Oliveira4 Elisangela Aparecida Felipe5 Dayana Freitas6 Leila Maria Marchi-Alves7 Objective: to evaluate the indexes and the main factors associated with non-adherence to medication treatment for systemic arterial hypertension between urban and rural areas. Method: analytical study based on an epidemiological survey with a sample of 247 hypertensive residents of rural and urban areas, with application of a socio-demographic and economic questionnaire, and treatment adherence assessment. The Pearson’s Chi-square test was used and the odds ratio (OD) was calculated to analyze the factors related to non-adherence. Results: the prevalence of non-adherence was 61.9% and it was higher in urban areas (63.4%). Factors significantly associated with non-adherence were: male gender (OR=1.95; 95% CI 1.08-3.50), age 20-59 years old (OR=2.51; 95% CI 1.44-4.39), low economic status (OR=1.95; 95% CI 1.09-3.47), alcohol consumption (OR=5.92, 95% CI 1.73-20.21), short time of hypertension diagnosis (OR=3.07; 95% CI 1.35-6.96) and not attending the health service for routine consultations (OR=2.45; 1.35-4.42). Conclusion: the socio-demographic/economic characteristics, lifestyle habits and how to relate to health services were the factors that presented association with nonadherence regardless of the place of residence. Descriptors: Hypertension; Medication Adherence; Urban Population; Rural Population.
Paper extracted from doctoral dissertation “Systemic arterial hypertension in urban and rural population of Sacramento/MG: prevalence
1
and non-adherence to medication treatment”, presented to Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil. Doctoral student, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research
2
Development, Ribeirão Preto, SP, Brazil. Assistante Professor, Universidade Federal de Uberlândia, Uberlândia, MG, Brazil. Doctoral student, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, WHO Collaborating Centre for Nursing Research
3
Development, Ribeirão Preto, SP, Brazil. Scholarship holder from Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil. Doctoral student, Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil. Scholarship
4
holder from Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil. Social worker, Escola Eurípedes Barsanulfo, Sacramento, MG, Brazil.
5
Doctoral student, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Centro Colaborador da OMS para o Desenvolvimento
6
da Pesquisa em Enfermagem, Ribeirão Preto, SP, Brazil. RN, UBS/PSF Gilberto Arthur Abate, Prefeitura Municipal de Frutal, Frutal, MG, Brazil. PhD, Professor, Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Centro Colaborador da OMS para o Desenvolvimento da
7
Pesquisa em Enfermagem, Ribeirão Preto, SP, Brazil. Corresponding Author: Patrícia Magnabosco Universidade Federal de Uberlândia. Faculdade de Medicina Av. Pará, 1720 Bairro: Umuarama CEP: 38400-902, Uberlândia, MG, Brasil E-mail: [email protected], [email protected]
Copyright © 2015 Revista Latino-Americana de Enfermagem This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC). This license lets others distribute, remix, tweak, and build upon your work non-commercially, and although their new works must also acknowledge you and be non-commercial, they don’t have to license their derivative works on the same terms.
Magnabosco P, Teraoka EC, Oliveira EM, Felipe EA, Freitas D, Marchi-Alves LM.
Introduction
21
of the disease, ignorance, illness in the family context
Non-adherence
to
medication
therapy
is
a
worldwide problem by reducing the therapeutic results, especially chronic diseases, and increasing the costs of health systems(1). Conceptually, non-adherence should be assumed as a multi-dimensional construct. It is related not only to medication intake or not, but to how the patients “manage” their treatment: behavior in relation to dose, time, frequency and duration(2).
and self-esteem) and how people with SAH relate with the health service(1). Thus, given the diversity of contexts between residents of urban and rural areas, this study aims to evaluate the indexes and the main factors associated with non-adherence to medication treatment for SAH between urban and rural areas of a Brazilian city.
Method
Few studies in Brazil and around the world describe
The study was conducted in a city located in the
the adherence rates among hypertensive patients,
Triângulo Mineiro, region of Alto Paranaíba in the State
especially in rural areas. Most investigations have been
of Minas Gerais, which has a population of 23,880
focused on the evaluation in urban centers and these
inhabitants, with 19,278 living in the urban area and
data cannot be extended to rural areas, as populations
4,602 in the rural area. The population aged 20 years
have very different demographic characteristics, food
or older is 14,217 people, with 12,974 in the urban and
and cultural habits, occupation types and access to
1,243 in the rural area(13). The coverage of the Family Health Strategy (FHS)
health care . (3)
The literature shows that the prevalence of
in the city is 85.9% and it has six teams, one with only
non-adherence of people with Systemic Arterial
rural activities, covering approximately 700 families
Hypertension (SAH) to medication treatment is quite
distributed in six micro-areas. The long distances
varied (4). Research conducted with hypertensive
and difficult traffic conditions and mobility between
patients in outpatient clinics of Brazilian hospitals
areas are some of the main challenges for interaction
showed a percentage of non-adherence of 86.7% in
with rural communities, historically relegated to low
São José do Rio Preto (SP) (5) and 12.7% in Ribeirão
priority.
. In the primary care of a small town
For this study, we investigate a population of 1,243
in Rio Grande do Sul, the non-adherence rate was
adults registered in the rural FHS and 4,690 people
34.3% (7).
was
enrolled in two FHS teams in the urban area. The
and, in Maringá (PR), it was equal to
sample size determination was based on the population
Preto (SP)
26.8%
(8)
(6)
In
Teresina
(PI),
non-adherence
proportion estimate, using a SAH prevalence rate equal
64.0% (9). Studies in rural areas of different countries have
to 44%, maximum value according to studies conducted
also shown varying rates of non-adherence to medication
in Brazil(14). Individuals were selected through random
treatment for SAH. Rates of 66.0% in Turkey(10) and
sampling that included 5,933 adult inhabitants resident
60.1% in the United States
were found. In Brazil, a
in rural and urban areas, with correction for finite
study conducted in the state of Minas Gerais showed
populations and adjustment for a refusal population of
non-adherence rate of 28%(12).
20%, respecting the population density of each area.
(11)
The world report shows that this variability in the frequency of adherence depends on the method used for its estimation, population characteristics investigated
The confidence interval was set as 95% and the design error as 2.5%. For each area covered by the FHS teams, a sample corresponding to 563 participants from urban and 153
and the sample size . (1)
Regarding the factors that influence treatment
from rural areas was estimated. For the data collection
adherence, researchers point out multiple causes, i.e.
procedure, a sample draw was performed in four stages.
adherence depends on the disease (chronicity, absence
The sampling units of the first stage were carried out
of
according to the FHP coverage areas of urban and rural
symptoms
and
late
consequences),
treatment
(medication consumed), characteristics and beliefs
regions of the municipality.
of people (gender, age, ethnicity, marital status,
In the urban area, the second stage comprised
education and socio-economic status), life habits,
sampling by street, the third by residences, and
cultural aspects (lack of perception of the seriousness
the fourth by choosing a resident. To maintain and
www.eerp.usp.br/rlae
22
Rev. Latino-Am. Enfermagem 2015 Jan.-Feb.;23(1):20-7.
ensure the random characteristic of the sample, it
this study(16); difficulty to access the health services;
was determined that the selection of individuals would
type of health service used (health insurance/private
include the individual with the first upcoming birthday,
or SUS); reason why the health service was searched
from the date of the interview, among the inhabitants of
(only in emergency cases, for routine consultations -
the residence drawn.
at least one medical visit every six months(14) - or to
The selection of participants in the rural area occurred by random drawing from the numeric register
get medications) and amount of anti-hypertensive pills prescribed a day.
of families in the FHS, registered in the Primary Care
For the assessment of non-adherence to treatment
Information System (SIAB) of the Municipal Health
of SAH, the instrument “Questionnaire of Adherence to
Secretariat. For the selection of the individuals, the
Medications - Qualiaids” (QAM-Q) was used, developed
criterion valid for the urban population was used.
and
validated
in
Brazil(2).
The
questionnaire
was
Preliminarily, the individuals were informed about
developed to address the act (if the individual takes and
the objectives and procedures of the study and, next,
how much medication is taken), the process (such as
they were invited to participate in the study. The data
how medication is taken in seven days, if he/she skips, if
collection was carried out after signing the Informed
he/she takes it abnormally, if he/she has “breaks”) and
Consent Form (ICF). The sample included individuals
the adherence results (in this case, if his/her pressure
aged 20 years or older who reported having SAH and
was under control).
excluding pregnant women and people with serious
To
sort
the
interviewee
as
non-adherent
a
psychiatric illness or mental disability informed by a
composite measure was constructed, in which the
relative. These criteria determined the subject studied
presence of one of these conditions was sufficient:
in 247 hypertensive patients (194 in urban areas and 53
either not taking the correct amount (80% - 120% of
in rural areas).
the prescribed doses), or not taking it the right way
Data collection was carried out between January and
(without “breaks”, “erratic intake”, abandonment or
August 2013, through a semi-structured questionnaire
“partial adherence”), or to report that his/her blood
and instruments that permitted the evaluation of socio-
pressure was altered(2).
demographic and economic variables, risk factors for
To analyze the association between the dependent
SAH, knowledge of hypertensive condition, medications
variable (non-adherence to treatment of SAH) and
in use, access to health services and reasons why
socio-demographic and economic variables, clinical/
participants seek care.
treatment/lifestyle
Non-adherence
to
medication
treatment
and
access
to
health
services,
of
Pearson’s Chi-square test was used. The odds ratio
SAH was the dependent variable addressed and the
(OD) was calculated with the respective 95%confidence
independent variables of interest were: gender; age
intervals for each variable studied. The significance
(young/adult or elderly); skin color reported according
level was set as α=0.05. The software SPSS Windows
to the perception of the individual (white or non-white);
Statistical Package for the Social Sciences (SPSS),
years of education (< 8 years or ≥ 8 years); economic
version 17.0 was used.
status (classified based on the criteria of the Economic
This study was approved by the Research Ethics
Classification of Brazil according to the Associação
Committee of the University of São Paulo at Ribeirão
Brasileira de Empresas de Pesquisa(15), which takes
Preto College of Nursing (EERP-USP) under protocol
education and consumer goods for reference, where
188/2012.
the variation occurs between Class A, which is the best stratum, up to class E, with the most unfavorable conditions);
sedentary
lifestyle
(not
Results
performing
physical activity at least three times/week for at least
The prevalence of non-adherence to medication
30 minutes/day); smoking (consumption of at least one
treatment of SAH as a combined measure of QAM-Q
cigarette/day); alcohol consumption (consumption of
was 153 (61.9%), being higher in the urban area,
more than 30 g of ethanol/day for men and 15g/day for
123 (63.4%), than in rural area, 30 (56.6%). No
women)
; time of diagnosis of SAH (up to 3 years or
association was found between place of residence and
≥ 3 years), according to criteria adopted by the authors
non-adherence to treatment (OD= 1.32; 95% CI 0.71-
of the non-adherence measurement instrument used in
2.46).
(14)
www.eerp.usp.br/rlae
23
Magnabosco P, Teraoka EC, Oliveira EM, Felipe EA, Freitas D, Marchi-Alves LM. The distribution frequencies of socio-demographic and
economic
characteristics,
clinical/treatment/
lifestyle and access to health services in urban and rural populations are shown in Tables 1 and 2.
Table 1 - Distribution of hypertensive patients according
Table 2 - (continuation) Rural (n=53) %
Urban (n=194) %
Total (n=247)
Routine visit*
62.3
64.4
63.6
To get medication
5.7
7.6
3.6
Only emergency
32.1
28.8
32.8
Study variable % Reason for seeking the health service
to socio-demographic/economic and lifestyle variables of urban and rural population. Sacramento, MG, Brazil, 2013
* Routine visit (at least one medical visit every 6 months)
Non-adherence
measured
by
the
proportion
Rural (n=53) %
Urban (n=194) %
Total Population (n=247)
Female
56.6
72.7
69.2
population and 16 (30.2%) in rural areas. As regards
Male
43.4
27.3
30.8
taking the medication measured by the QAM-Q, 82
≥ 60 years old
39.6
66.0
60.3
Up to 59 years old
60.4
34.0
39.7
White
92.5
73.2
77.3
Non-white
7.5
26.8
22.7
< 8 years of study
84.9
71.6
74.5
≥ 8 years of study
15.1
28.4
25.5
A/B
13.2
29.4
25.9
took it erroneously in urban areas and six (11.3%) in
C/D/E
86.8
70.6
74.1
rural areas; 15 (7.7%) had half adherence in urban
No
84.9
85.6
85.4
Yes
15.1
14.4
14.6
No
88.7
90.2
88.7
Yes
11.3
9.8
11.3
Study variable % Gender
Age Group (years)
Skin color
of dosages of QAM-Q was 53 (27.3%) in the urban
(42.3%) people were considered non-adherent in the urban area and 21 (39.6%) in rural areas; of these, 12 (6.2%) in the urban area and three (5.7%) in rural areas reported taking medications at changed times; 10 (5.2%) people in the urban area had “breaks” in
Education
Economic Status*
Smoking†
Alcohol consumption‡
* Economic Status A/B (more favorable) and C/D/E (less favorable) † Smoking (consuming at least one cigarette/day) ‡ Alcohol consumption (consumption of more than 30 g ethanol/day for men and 15g/day for women).
the use of antihypertensive medications, but none among hypertensive patients in rural areas; 20 (10.3%)
areas and seven (13.2%) in rural areas; six (3.1%) exchanged dose levels in the urban and one (1.9%) in the rural area; three (1.5%) partially abandoned medication treatment in the urban and none in the rural area; 21 (10.8%) totally abandoned the medication in the urban and five (9.4%), in the rural population. Regarding treatment results, 87 (44.8%) residents in the urban and 20 (37.7%) in the rural area reported
Table 2 - Distribution of hypertensive patients according
that their blood pressure was altered the last time it
to clinical variables/treatment and access to health
was measured.
services in urban and rural population. Sacramento, MG, Brazil, 2013 Study variable %
Rural (n=53) %
Urban (n=194) %
Total (n=247)
Time of diagnosis (Systemic Arterial Hypertension)
The frequency distribution and association between non-adherence and the variables studied are presented in Tables 3 and 4. The reasons reported by the hypertensive patients
More than 3 years
77.4
77.8
83.0
Up to 3 years
22.6
22.2
17.0
1 to 2
48.1
53.8
52.3
forgetfulness (16.8%), economic factors (5.9%) and
≥3
51.9
46.2
47.7
others (4.2%).
Health Insurance/Private
3.8
22.7
23.9
Brazilian Unified Health System
96.2
77.3
76.1
Pills/day
Service Type
relative to non-adherence to medication treatment were: absence of symptoms (51.3%), side effects (21.8%),
The factors that hampered the access to health services were: distance in relation to the local of care (77.6%) and lack of vacancies (15.6%) according to the
Difficulty to access No
60.4
68.8
66.4
residents of the rural area, and availability of vacancies
Yes
39.6
32.0
33.6
(46.0%) and limited mobility (44.4%) according to
(continue...)
www.eerp.usp.br/rlae
urban population.
24
Rev. Latino-Am. Enfermagem 2015 Jan.-Feb.;23(1):20-7.
Table 3 - Univariate analysis of the association between non-adherence and socio-demographic/economic and lifestyle characteristics. Sacramento, MG, Brazil, 2013 Study variable
Non-adherence(%)
Likelihood Ratio
Rural (n=53)
Urban (n=194)
Total (n=247)
Female
50.0
58.9
57.3
1
Male
65.2
75.5
72.4
1.95
≥ 60 years old
47.6
54.7
53.7
1
Up to 59 years old
62.5
80.3
74.5
2.51
White
59.2
60.6
60.2
1
Non-white
25.0
71.2
67.9
1.39
< 8 years of study
55.6
62.6
60.9
1
≥ 8 years of study
62.5
65.5
65.1
1.19
A/B
42.9
50.9
50.0
1
C/D/E
58.7
68.6
66.1
1.95
No
55.9
60.8
59.7
1
Yes
62.5
78.6
75.0
2.02
No
53.2
60.6
58.4
1
Yes
83.3
89.5
89.3
5.92
Gender
Age Group (years)
Skin color
Education
Economic status †
Smoking‡
Alcohol consumption§
* † ‡ §
Confidence Interval (95%)
p*
(1.08-3.50)
0.025‡
(1.44- 4.39)
0.001‡
(0.74-2.62)
0.301
(0.66-2.17)
0.553
(1.09-3.47)
0.023‡
(0.90-4.51)
0.081
(1.73-20.21)
0.002‡
Pearson’s chi-square test (p
